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April 30, 2025 Catawba Indian Nation Attn: Chief Brian Harris 996 Avenue of the Nations Rock Hill, SC 29730 Subject: Community Engagement Section 1115 Demonstration Waiver Dear Chief Harris: On behalf of the State of South Carolina Department of Health and Human Services (SCDHHS) and in keeping with the responsibility to conduct tribal consultation, I am writing to inform you that SCDHHS has started the public comment period for the Section 1115 demonstration waiver titled “The Palmetto Pathways to Independence” that will be submitted to the Centers for Medicare and Medicaid Services (CMS). The demonstration application is attached and can also be found online at www.scdhhs.gov/cewaiver. As we first notified you on March 26, 2025, the new Section 1115 demonstration waiver will create a coverage pathway for families whose income is currently too high to qualify for Medicaid but too low to qualify for federal subsidies in the federal marketplace. The demonstration seeks to build a state-specific solution to eliminate the financial disincentives for employment that currently exist due to the Patient Protection and Affordable Care Act’s (ACA) all or nothing approach to Medicaid expansion. The Palmetto Pathways to Independence waiver program will establish a new eligibility pathway for adults aged 19-64 who otherwise meet eligibility criteria under the PCR coverage group and have an income that is 67% to 95% of the federal poverty level (FPL) with a 5% disregard, effectively including individuals between 67%-100% FPL. South Carolina’s goals for the demonstration are to incentivize employment and close the health care coverage gap created by the ACA. The demonstration will support strategies to: • Remove health-related barriers to employment; • Promote member transition to commercial health insurance; and • Support the long-term, fiscal sustainability of the Healthy Connections Medicaid program. Individuals eligible for the demonstration will be required to participate in 80 hours per month of community engagement activities to gain and maintain Medicaid coverage. Qualifying community engagement activities include: • Employment for no less than 80 hours per month; 35